The American College of Rheumatology’s latest recommendations on treatment of osteoarthritis place new emphasis on early use of nonpharmacologic therapies, such as tai chi and acupuncture and advise against use of glucosamine/chondroitin.
"We placed an emphasis on non-pharmacologic treatments. ... Reimbursement is one of the issues. We really wanted to put some gravitas on the evaluation of the non-pharmacologic modalities. ... We wanted providers to be aware of what’s available for patients, what’s beneficial for patients, and what the recommendations of a group of experts are on how they should use these for patients even before they consider pharmacologic agents."
The new recommendations, which are ACR’s first to address hand OA, are also the first to be developed using a formal process for evidence-based recommendations. They "were derived using a state-of-the-art approach utilizing evidence from the most recent and best methodological quality systematic review of the individual treatment modalities in patients with osteoarthritis of the hand, hip, or knee," lead author Dr. Marc C. Hochberg said in an interview.
The approach, called Grades of Recommendation Assessment, Development, and Evaluation (GRADE), has been adopted by the World Health Organization, the Cochrane Collaboration, and the Agency for Healthcare Research and Quality, along with numerous professional organizations. The American College of Rheumatology has now officially adopted GRADE for future recommendations, said Dr. Hochberg, professor of medicine and epidemiology and public health and head of the division of rheumatology and clinical immunology at the University of Maryland, Baltimore.
The new recommendations, which replace those issued in 2000, are also the first to be developed by a multidisciplinary panel that included primary care physicians, physiatrists, and geriatricians along with rheumatologists (both academic and private practice), an orthopedic surgeon, and both physical and occupational therapists. Based on the strength of the evidence and using real-life patient examples, the panelists ranked each recommendation as either strong in favor of use, weak (or conditional), no recommendation, weak or conditional recommendation not to use, and strong recommendation not to use (Arthritis Care Res. 2012;64:465-74).
"These are much more real-world recommendations based on patients who present for consultation and would be applicable for the provider in their office situation when they see a patient. ... They’re meant for primary care physicians as well as rheumatologists," Dr. Hochberg said.
In fact, the new emphasis on non-pharmacologic therapies is done for the benefit of primary care physicians. "In the short period of time that primary care providers have to spend with their patients, [non-pharmacologic therapies are] often overlooked," said Dr. Hochberg.
For hand OA, the panel conditionally recommended evaluation of the patient’s ability to perform activities of daily living, instruction in joint protection techniques, assistive devices as needed, instruction in the use of thermal modalities, and splints for patients with trapeziometacarpal joint OA. Conditional pharmacologic recommendations for hand OA include topical capsaicin, topical nonsteroidal anti-inflammatory drugs (NSAIDs), and oral NSAIDs. The panel also conditionally recommended against the use of intra-articular therapies and opioid analgesics.
No strong recommendations were made for hand OA. "We only provided conditional recommendations for hand OA, which points to the relative dearth of studies in this area and then lack of good quality evidence to support treatments for it. Hand OA is an area that is in need of well-designed, large placebo-controlled and active-comparator studies," Dr. Hochberg commented.
For initial management of knee OA, the panel strongly recommended the nonpharmacologic interventions of participation in cardiovascular (aerobic) and/or resistance land-based exercise, participation in aquatic exercise, and weight loss if indicated. They conditionally recommended a long list of nonpharmacologic interventions, including participation in self-management programs, manual therapy in combination with supervised exercise, psychosocial intervention, use of medially directed patellar taping, wedged insoles, thermal agents, walking aids as needed, participation in tai chi programs, treatment with Chinese acupuncture, and transcutaneous electrical stimulation.
No strong pharmacologic recommendations were made for the initial treatment of knee OA. Conditional recommendations included one of the following: acetaminophen, oral NSAIDs, topical NSAIDs, tramadol, or intra-articular corticosteroid injections. Conditional recommendations were made to not use chondroitin sulfate, glucosamine, or topical capsaicin.
Strong nonpharmacologic recommendations for hip OA included participation in cardiovascular and/or resistance land-based exercise, participation in aquatic exercise, and weight loss, if indicated. Conditional nonpharmacologic recommendations included participation in self-management programs, manual therapy in combination with supervised exercise, psychosocial interventions, instruction in the use of thermal agents, and walking aids as needed.
As with knee OA, conditional pharmacologic recommendations for hip OA include one of either acetaminophen, oral NSAIDs, tramadol or intra-articular corticosteroid injections. As well, chondroitin sulfate and glucosamine were conditionally recommended against.